[Epidemiological surveillance: family doctors' responsibility]. / Surveillance épidémiologique: une responsabilité du médecin de famille.

Epidemiological surveillance systems are essential and require efficient collaborations between family doctors and public health services. Such a system has to take into account the increase in the number of health problems to be studied. Information gathered at an individual level should imply decisions at a population level which in turn should impact on the individual patient. Epidemiological surveillance requires a well organized, representative and constantly revised system led by motivated, adequately trained doctors.

Trend of burnout among Swiss doctors.

QUESTION UNDER STUDY: Over the last decade the Swiss health care system has undergone several changes, resulting in stronger economic constraints, a heavier administrative workload and limited work autonomy for doctors. In this context we examined the change in burnout prevalence over time among Swiss doctors surveyed during this period. METHODS: Cross-sectional survey data collected by mail in 2002, 2004 and 2007 throughout the country were used. Measures included the Maslach Burnout Inventory (MBI), several socio-demographics (gender, living alone, having children), and work-related characteristics (number of years in current workplace, hours worked). Answers to the MBI were used to classify respondents into moderate (high score on either the emotional exhaustion or the depersonalisation/cynicism subscale) and high degree of burnout (scores in the range of burnout in all three scales). RESULTS: Rates of moderate-degree burnout increased from 33% to 42% among general practitioners (p = 0.002) and from 19% to 34% among paediatricians (p = 0.001) (high degree of burnout: 4% to 6% [p = 0.17] and 2% to 4% [p = 0.42] respectively). After adjustment for significant socio-demographic and work-related characteristics, an increased risk of moderate burnout was found for doctors surveyed in 2004 and 2007 (OR 1.6, 95%CI 1.3 to 2.0), general practitioners (OR 1.6, 95%CI 1.3 to 2.0) and French-speaking doctors (OR 1.5, 95%CI 1.3 to 1.9). An increased risk of high-degree burnout was found only for general practitioners (OR 1.8, 95%CI 1.05 to 3.0). CONCLUSIONS: Burnout levels among Swiss doctors have increased over the last decade, in particular among French-speaking doctors.

[Back pain in primary care: a changing paradigm over time]. / Lombalgie et médecin généraliste: des soins de premier et de dernier recours.

Acute lumbar pain is a frequent problem in primary care. Specific problems can be easily ruled out based on personal history and clinical examination in the absence of the so called "red flags". The primary care doctor must then avoid to prescribe any unnecessary additional test, but emphasize the "functional" nature of the problem and the absence of organic lesions. Reassurance and prompt mobilization are key elements for a quick recovery. When lumbar pain becomes chronic, a therapeutic agenda based only on the biomedical model will fail, because causative organic lesions are generally absent. Instead, the bio-psychosocial approach can help to reestablish a favourable doctor-patient relationship, which integrates an active participation of the patient to establish common therapeutic goals.

Detecting drug interactions using personal digital assistants in an out-patient clinic.

BACKGROUND: The installation of drug databases on personal digital assistants (PDAs) allows for rapid detection of adverse drug interactions at the point of care. AIM: To test the ability of a drug interaction database (ePocrates RX) to correctly identify clinically significant adverse drug interactions in an out-patient setting. DESIGN: Retrospective file review of 1801 drug prescriptions in out-patients consulting a medical walk-in clinic. METHODS: Each prescription was assessed independently by a clinical pharmacologist using drug-drug interaction compendia, and by a general internist using the drug interaction database. Discrepant results were systematically reviewed by both, using published literature, and a consensus was then reached. This consensus was used as the criterion against which the PDA drug interaction database was judged. RESULTS: The prevalence of potential adverse drug interactions was 23%. When compared to the opinion of the clinical pharmacologist and drug-drug interaction compedia, the sensitivity of the drug interaction database to correctly identify clinically relevant adverse drug interactions was 81% (95%CI 77%-85%) and the specificity was 88% (95%CI 86-89%). The positive predictive value was poor (67%, 95%CI 62%-71%) but the negative predictive value was excellent (94%, 95%CI 92%-95%). DISCUSSION: The database was an efficient tool for rapidly checking for potentially harmful drug interaction, but also flagged up several clinically non-significant interactions. When used appropriately, this drug interaction database could help physicians decrease prescription error, by ruling out the risk of clinically relevant adverse drug interactions for newly prescribed drugs, and thereby increase patient safety.

Immunogenicity and safety of a virosomal hepatitis A vaccine in HIV-positive patients.

This short report presents results of an open uncontrolled single centre study which evaluated immunogenicity and safety of a virosome-formulated hepatitis A vaccine (Epaxal) in 14 HIV-positive adult patients and 64 healthy adults receiving a primary immunisation and a booster dose 12 months later. Seroconversion rates (> or =20 mIU/mL), geometric mean concentration (GMC) of anti-HAV antibodies, local and systemic adverse events (AEs) were assessed at baseline and at Months 1, 6, 12, and 13. The seroconversion rate was 63.6% at Month 1 and 91.7% at Month 13 in HIV-positive patients versus 93.8 and 100% in healthy adults. The booster dose increased GMCs from 25.5 to 659.2 mIU/mL in HIV-positive patients versus 104 and 2986 mIU/mL in healthy adults. Epaxal was well tolerated by the HIV-positive patients and was at least as immunogenic as reported for aluminium-adsorbed vaccines. In conclusion, Epaxal can be considered an immunogenic and safe hepatitis A vaccine in HIV-positive patients.

Long-term effectiveness of a multifaceted intervention on pain management in a walk-in clinic.

BACKGROUND: Pain is a common complaint of patients attending walk-in clinics, but timely and appropriate pain management is often lacking. AIM: To evaluate the impact of a multifaceted intervention on pain management. DESIGN: Prospective interventional study. METHODS: Three cross-sectional surveys were conducted: before, 4 months after and 14 months after a multifaceted intervention at the medical walk-in clinic of a university hospital. The intervention included both educational activities and structural changes. Use of recommended pain management procedures, pain relief and overall assessments of pain treatment and health professionals' attitudes were assessed using patient questionnaires, collected by mail. History of pain, records of pain intensity and use of pain medication were extracted from medical files. RESULTS: We analysed 1409 medical files and 695 questionnaires of patients presenting with pain. Documentation of pain intensity and administration of pain medication at the walk-in clinic improved significantly 14 months after the intervention (7% vs. 53% and 17% vs. 27%, respectively, p<0.001) and pain medication was more often administered by the oral route (14% vs. 23%, p<0.001). However, no change was observed for complete pain relief (40% vs. 39%, p=0.92) or patients' overall assessments of pain management. DISCUSSION: The intervention improved adherence to recommended procedures, even in the longer term, but did not result in better patient outcomes. Continuing efforts are needed to help health professionals improve pain management in out-patient care.

[Quality care in primary care: the importance of patients' reports]. / Qualité des soins en médecine de premier recours: "a l'ecoute de nos patients".

Patients' evaluation of care is an important element of quality of care, especially for patients with chronic conditions. Our objective was to expose physicians in training to a quality improvement program and study how continuity of care could influence patients' experience of care. Physicians in training valued this approach, but deplored no to be actively involved in its planning. They also underlined the importance of keeping physicians' individual results absolutely confidential. Positive patients' reports toward communication and physician-patient relationship were associated with longer duration of follow-up at the medical outpatient clinic. Following this project, several changes have been made to improve aspects of care that were problematic.

[Preparing a drug list for primary care]. / Prescription en médecine de premier recours: l'intérêt d'une liste de médicaments.

To limit drug adverse effects, the use of a limited choice of drugs is desirable. We identified 29 frequent health problems and selected first and second choice medication based on the following criteria: clinical efficacy based on medical evidence or expert consensus, safety profile, and costs. For each substance, adverse effect, contraindication, interaction risk, specific dosing, and safety use during pregnancy and lactation were reviewed. More than seventy substances were identified. This list is available for download at the following address (in French): http://www.hcuge.

[Initial management of hypertension in a primary care service]. / Prise en charge initiale de l'hypertension artérielle en médecine de premier recours: un etat des lieux.

The management of hypertension in Switzerland follows the Guidelines of the European Society of Hypertension and Cardiology (ESH-ESC 2003). The aim of our survey was to evaluate to what extent initial check-up and determination of the absolute cardiovascular risk of hypertensive patients are performed by residents of a medical outpatient clinic. Hypertension is a very frequent condition in this kind of consultation, 1 patient in 3 being treated for a high blood pressure. Despite of this, the initial evaluation of the absolute cardiovascular risk is not performed in accordance with the guidelines. The assessment of diabetes or dyslipidemia and the search for target organ damage are not systematically done, even in case of high blood pressure values (grade I-III).

Patient assessments of a hypothetical medical error: effects of health outcome, disclosure, and staff responsiveness.

OBJECTIVE: To assess whether patients' perceptions of a hypothetical medical error are influenced by staff responsiveness, disclosure of error, and health consequences of the error. DESIGN: Hypothetical scenario describing a medication error submitted by mail. Three factors were manipulated at random: rapid v slow staff responsiveness to error; disclosure v non-disclosure of the error; and occurrence of serious v minor health consequences. PARTICIPANTS: Patients discharged from hospital. MEASURES: Assessment of care described in the scenario as bad or very bad, rating of care as unsafe, and intent to not recommend the hospital. RESULTS: Of 1274 participants who evaluated the scenario, 71.4% rated health care as bad or very bad, 60.2% rated healthcare conditions as unsafe, and 25.5% stated that they would not recommend the hospital. Rating health care as bad or very bad was associated with slow reaction to error (odds ratio (OR) 2.8, 95% CI 2.1 to 3.6), non-disclosure of error (OR 2.0, 95% CI 1.5 to 2.6), and serious health consequences (OR 3.4, 95% CI 2.6 to 4.5). Similar associations were observed for rating healthcare conditions as unsafe and the intent to not recommend the hospital. Younger patients were more sensitive to non-disclosure than older patients. CONCLUSIONS: Former patients view medical errors less favorably when hospital staff react slowly, when the error is not disclosed to the patient, and when the patient suffers serious health consequences.

Acceptability of identification bracelets for hospital inpatients.

OBJECTIVE: To evaluate whether hospitalised patients would agree to wear an identification bracelet and whether patient acceptability is improved by more detailed explanations or by using a code instead of a name on the bracelet. DESIGN: Patient survey that tested two variables in a randomised factorial design. Explanations about identification bracelets were given (a) with or without examples of situations where patient identification may be important, and (b) with the patient name or an anonymous code appearing on the bracelet. SETTING: Swiss teaching hospital where wearing of identification bracelets was not systematic. PARTICIPANTS: Adult patients discharged from hospital (n = 1411). MAIN OUTCOME MEASURES: Patients' responses to the questions: (a) should the hospital introduce a compulsory identification bracelet? and (b) would the patient agree to wear such a bracelet? RESULTS: Globally, 83.9% of patients thought that the hospital should introduce bracelets and 90.2% stated that they would agree to wear one. Providing examples increased support for both the hospital policy (87.9% v 79.2%, p<0.001) and personal acceptance (92.2% v 88.1%, p = 0.015). Whether or not the bracelet carried the patient's name or an anonymous code did not influence patient choice. CONCLUSIONS: The majority of patients were in favour of wearing an identification bracelet during their hospital stay. This proportion increased significantly when an explanation based on examples of the consequences of incorrect patient identification had been provided.

Prospective evaluation and comparison of the direct agglutination test and an rK39-antigen-based dipstick test for the diagnosis of suspected kala-azar in Nepal.

The diagnosis of visceral leishmaniasis (kala-azar) remains difficult in rural endemic areas and practical and reliable tests are badly needed. Two serological tests, the Direct Agglutination Test (DAT) and an rK39-antigen-based dipstick test, were compared to parasitological diagnosis in a group of 184 patients presenting at a tertiary care centre in south-eastern Nepal with a history of fever > or = 14 days and splenomegaly; 139 patients had a parasitologically proven kala-azar and 45 patients had a negative parasitological work-up. The rK39 dipstick showed a sensitivity of 97% and a specificity of 71%. The DAT was up to 99% sensitive with a low cut-off titre (1:400) but its specificity did not exceed 82% even with a high cut-off titre (1:51 200). Both tests could be used for screening suspect patients in endemic areas. However, their use as confirmatory tests should be restricted to situations where the proportion of kala-azar among clinical suspect patients is high. The rK39 dipstick is cheaper and easier to use than the DAT and could be used widely provided that both its performance and production remain stable.

Treatment of visceral leishmaniasis in south-eastern Nepal: decreasing efficacy of sodium stibogluconate and need for a policy to limit further decline.

Sodium stibogluconate (SSG) is the first-line therapy for visceral leishmaniasis (VL) in south-eastern Nepal. Recent studies from the neighbouring state of Bihar, India, have shown a dramatic fall in cure rates with treatment failure occurring in up to 65% of VL patients treated with SSG. A prospective study was conducted at a tertiary-level hospital located in south-eastern Nepal from July 1999 to January 2001. Parasitologically proven kala-azar patients with no previous history of treatment for VL were treated with SSG 20 mg/kg/d for 30 d which was extended to 40 d in those with persistent positive parasitology. Of the 110 patients who completed SSG therapy and were assessed at 1 and 6 months, definite cure was achieved in 99 patients (90%) and SSG failure occurred in 11 patients (10%). Except for the presence of hepatomegaly and a lower platelet count there was no clinical or laboratory baseline characteristic associated with treatment failure. A significantly lower cure rate (76%, P = 0.03) was observed in patients from the district of Saptari, which borders the antimony-resistant VL areas of Bihar. The efficacy of SSG as a first-line treatment for VL in south-eastern Nepal was still satisfactory, except for the patients living closer to the antimony-resistant VL areas of India. These findings indicate that the spread of resistance to antimonials is already taking place in Nepal and that a policy to control further spread should be urgently implemented.

Long-term immunogenicity of an inactivated virosome hepatitis A vaccine.

The aim of this study was to predict the long-term protection induced after immunisation with inactivated, aluminium-free virosome hepatitis A vaccine. The study population consisted of adult volunteers enrolled in four different clinical trials. Lower 95% confidence interval limits and seroconversion rate were calculated by using a linear mixed model to estimate the persistence of serum antibodies over time. To assess the robustness of the mathematical model, several sensitivity analyses were performed with more conservative protective threshold (20 mIU/ml vs. 10 mIU/ml), higher yearly decline rate, and exclusion of volunteers who had increasing titres over time. Based on 190 volunteers with at least two valid assessments of titres from year 3 onward, the median duration of protection was 55.5 years, with a lower limit of the 95% CI of 48.7 years. Duration below 25.3 years was predicted for only 5% of the subjects. Women tended to have higher titres to start with, but their rate of decline was higher, resulting in similar duration of protection overall. The use of a more conservative threshold, higher yearly decline rate, and exclusion of volunteers with increasing titres over time did not affect these results. According to this model, 95% of the volunteers should have anti-HAV titres above the minimum protective threshold for 20 years or more following immunisation with two doses of this aluminium-free vaccine.

Field evaluation of the CATT/Trypanosoma brucei gambiense on blood-impregnated filter papers for diagnosis of human African trypanosomiasis in southern Sudan.

Most Human African Trypanosomiasis (HAT) control programmes in areas endemic for Trypanosoma brucei gambiense rely on a strategy of active mass screening with the Card Agglutination Test for Trypanosomiasis (CATT)/T. b. gambiense. We evaluated the performance, stability and reproducibility of the CATT/T. b. gambiense on blood-impregnated filter papers (CATT-FP) in Kajo-Keji County, South-Sudan, where some areas are inaccessible to mobile teams. The CATT-FP was performed with a group of 100 people with a positive CATT on whole blood including 17 confirmed HAT patients and the results were compared with the CATT on plasma (CATT-P). The CATT-FP was repeated on impregnated filter papers stored at ambient and refrigerated temperature for 1, 3, 7 and 14 days. Another 82 patients with HAT, including 78 with a positive parasitology, were tested with the CATT-FP and duplicate filter paper samples were sent to a reference laboratory to assess reproducibility. The CATT-FP was positive in 90 of 99 patients with HAT (sensitivity: 91%). It was less sensitive than the CATT-P (mean dilution difference: -2.5). There was no significant loss of sensitivity after storage for up to 14 days both at ambient and cool temperature. Reproducibility of the CATT-FP was found to be excellent (kappa: 0.84). The CATT-FP can therefore be recommended as a screening test for HAT in areas where the use of CATT-P is not possible. Further studies on larger population samples in different endemic foci are still needed before the CATT-FP can be recommended for universal use.

Patterns of use of ambulatory mental health services in a universal care setting.

OBJECTIVE: As health care expenditures grow, it is important to understand whether mental health services are being used appropriately. This study examined participants' reasons for seeking the services of a psychiatrist or psychologist to determine the extent to which factors other than an existing clinical disorder, such as culture, stress, or lack of social support, played a role. METHODS: A total of 1,257 randomly selected students who were enrolled at the University of Geneva in 1997 and who had unrestricted access to psychiatric services were asked how many times in the past 12 months they had consulted a psychiatrist or a psychologist. The respondents' mental health, perceived stress, self-esteem, sense of mastery, and social support were measured with validated instruments. RESULTS: A total of 131 respondents (10 percent) reported an encounter with a mental health provider in the past year. In adjusted analyses, female sex, Swiss citizenship, a higher level of stress, and a lower level of mental health were significantly associated with a greater number of visits to a mental health specialist, and self-esteem, sense of mastery, and social support were not. CONCLUSIONS: The respondents' use of mental health services was determined by a lower level of mental health, indicating appropriate use of services based on clinical need. However, service use was also determined by consumer-related variables such as perceived stress and sociocultural characteristics.

Importance of patients' perceptions and general practitioners' recommendations in understanding missed opportunities for immunisations in Swiss adults.

Over the last decades, tremendous efforts have been made to strengthen childhood immunisation programs. However, the burden of influenza and pneumococcal infections remains disturbingly high in adults and elderly. We conducted a cross-sectional self-administered mail survey to identify characteristics associated with low use of recommended vaccines in adult patients attending routine primary care appointments in Switzerland. Tetanus vaccination was reported by 84% of respondents aged 16-34, and by only 42% of respondents aged 65 or more. For influenza and pneumococcal vaccination, of high-risk patients (age > or =65 or history of diabetes, kidney, heart, or chronic pulmonary disease), only 41% were on schedule for influenza and 6% for pneumococcal vaccination. Compared with patients from the German- and Italian-speaking areas of the country, patients from the French-speaking region were more likely to report past immunisation against influenza and pneumococcal disease or a recent physician's recommendation for immunisation against influenza, but equally likely to have ever refused influenza vaccination. For all three diseases, area of residence, physician's recommendation for immunisation, and patient's perceived usefulness of vaccination were independently and significantly associated with vaccination status. Although patient's opinion is an important determinant of vaccination coverage in adults, lack of physician's encouragement accounted for most missed vaccination opportunities in this study. The higher vaccination coverage among patients from the French-speaking area suggests that the promotion campaigns carried out in this region effectively improved influenza vaccine use. Interventions designed to increase vaccination coverage in adults must help providers incorporate immunisation in routine health care.